MLT 132 Clinical Chem I

Week 4 CAL MAG PHOS/ pH/Acid /Base HW Assignment

Case Study 16-2 An 84-year-old nursing home resident was seen in the
emergency department with the following symptoms:
A 60-year-old man entered the emergency department nausea, vomiting, decreased respiration, hypotension,
after 2 days of “not feeling so well.” History revealed a and low pulse rate (46 bpm). Physical examination
myocardial infarction 5 years ago, when he was showed the skin was warm to the touch and flushed.
prescribed digoxin. Two years ago, he was prescribed a Admission laboratory data are found in Case Study
diuretic after periodic bouts of edema. An ECG at time of Table 16-3.1.
admission indicated a cardiac arrhythmia.
Serum Test/ Result Reference Range
Lab results :
Total protein 5.6 g/dL 6.0–8.0 g/dL
Venous Blood Albumin 3.0 g/dL 3.5–5.0 g/dL
Total Ca2+ 8.2 mg/dL 8.6–10.0 mg/dL
Digoxin: 1.4 ng/mL, therapeutic 0.5–2.2 (1.8 nmol/L, therapeutic 0.6–2.8)

Na+: 137 mmol/L

BUN 45 mg/dL 5–20 mg/dL
K+: 2.5 mmol/L Creatinine 2.3 mg/dL 0 0.7–1.5 mg/dL
Mg2+ 4.0 mmol/L 0.63–1.0 mmol/L
Cl−: 100 mmol/L
Plasma Na+ 129 mmol/L 136–145 mmol/L
HCO3 − : 25 mmol/L
K+ 5.3 mmol/L 3.4–5.0 mmol/L
Mg2+: 0.4 mmol/L Cl− 96 mmol/L 98–107 mmol/L
HCO3– 16 mmol/L 22–29 mmol/L
Ion/free Ca2+: 1.0 mmol/L

Questions :
Questions
1. Because the digoxin level is within the
therapeutic range, what may be the cause for 1. What is the most likely cause for the patient’s
the arrhythmia? symptoms?
2. What is the most likely cause for the 2. What is the most likely cause for the
hypomagnesemia? hypermagnesemia?
3. What is the most likely cause for the decreased 3. What could be the cause for the hypocalcemia?
potassium and ionized calcium levels?
1. The patient’s symptoms are relatively classic signs of
4. What type of treatment would be helpful?
hypermagnesemia: GI symptoms, decreased respiration,
1. Hypokalemia, hypocalcemia, and hypomagnesemia hypotension, bradycardia, and warm, flushed skin. 2.
are all possible causes for cardiac arrhythmia. Low Patients in nursing homes who have combined renal
magnesium and potassium levels can also cause problems and take magnesiumcontaining medications,
symptoms of digitalis toxicity. 2. Prolonged diuretic use such as antacids, enemas, or cathartics, are at greatest
can lead to magnesium loss. 3. Hypomagnesemia can risk for hypermagnesemia. The patient in this case study
cause decreased levels of potassium and calcium. The had been treated for constipation within the past 24
exact mechanism for hypokalemia is not completely hours. It would have been wise for a creatinine
understood; however, it is known that magnesium is clearance test to have been performed prior to
required for normal Na+-K+ pump activity, which is administration of the laxative to ensure adequate renal
responsible for active transport of K+. Magnesium function to clear the increased intake of magnesium.
deficiency can impair PTH release and target tissue This patient was dialyzed to decrease the magnesium
response, leading to hypocalcemia. 4. Providing level. 3. Elevated magnesium can inhibit PTH release
magnesium therapy alone may correct the hypokalemia and target tissue response, causing hypocalcemia. A
and hypocalcemia. Replenishment of either potassium or second cause may be hypoalbuminemia. Because total
calcium alone often does not remedy the disorder unless calcium measurement assesses both free and bound
magnesium therapy is provided. calcium, the bound fraction may be decreased as a
result of the decreased albumin.

Case Study 16-3

 MLT 132 Clinical Chem I

Week 4 CAL MAG PHOS/ pH/Acid /Base HW Assignment

Case Study 24-1

A 40-year-old woman presents to her physician

complaining of marked left flank pain that began the
previous night. She reports that the pain is worse than
that of giving birth. She also reports blood in her urine
earlier on the day she came to see her doctor. She has
felt more fatigued, and as if her concentration has not
been as good as normal for the last year or so, and she
Case Study 16-4
feels more forgetful. She has no significant past medical
Consider the following laboratory results from three adult history. She is taking no medications. Family history
patients (Case Study Table 16-4.1): contributes no pertinent information. On physical
examination, she appears to be in extreme pain. There
Case Ion Ca2+ Total Mg2+ PO4 is marked tenderness on very gentle percussion over the
(1.16-1.32 mmol/L) (0.63–1.0 mmol/l) 0.87–1.45 mmol/l
left costovertebral angle. Labs are drawn and are
notable for calcium 11.2 mg/dL (normal, 8.5 to 10.2
mg/dL), albumin 3.8 g/dL (normal, 3.5 to 4.8 g/dL), and
A 1.44 0.90 08.85
intact PTH 162 pg/mL (normal, 11 to 54 pg/mL). Renal
B 1.08 0.50 0.90 function is normal (BUN 25 mg/dL and creatinine 0.9
C 1.70 0.98 1.43 mg/dL). Urine analysis is notable for blood and >50 red
blood cells per high-power field. This prompts a 24-hour
urine collection, which reveals calcium elevated at 483
Questions:
mg per 24 hour (normal, 100 to 250 mg per 24 hour).
Which set of laboratory results (Case A, B, or C) is most
likely associated with each of the following diagnoses?
1. Which laboratory results are abnormal?
• Primary hyperparathyroidism
2. What is the presumptive diagnosis for this
______________________
patient? The differential diagnosis?
• Malignancy ____________________ 3. What treatment is indicated for this disease?

• Hypomagnesemic
hypocalcemia__________________________

Answers to Case Study 16-4

1. Case A: primary hyperparathyroidism Case

2. B: hypomagnesemic hypocalcemia
3. Case C: malignancy
 MLT 132 Clinical Chem I

Week 4 CAL MAG PHOS/ pH/Acid /Base HW Assignment

Case Study 24-3

A 26-year-old man presents to his physician 3 weeks Case Study 17-1

after having his thyroid surgically removed for thyroid
cancer. His doctor is certain that she “got it all.” A 50-year-old man came to the emergency department
However, since the time he went home from the hospital, after returning from foreign travel. His symptoms
he has noticed painful, involuntary muscle cramping. He included persistent diarrhea (over the past 3 days) and
also feels numbness and tingling around his mouth and rapid respiration (tachypnea). Blood gases were drawn
in his hands and feet. His girlfriend says he has been with the following results:
irritable for the last couple of weeks. His past medical pH = 7.21
history is notable only for the recent diagnosis of thyroid
pCO2 = 19 mm Hg
cancer, and its resection 3 weeks prior to this visit. His
only medication is levothyroxine. Family history pO2 = 96 mm Hg
contributes no relevant information. On physical HCO3 = 7 mmol/L
examination, he has a well-healing thyroidectomy scar.
Tapping on the face interior to the ears causes twitching sO2 96% (calculated) (reference range, >95%)

in the ipsilateral corner of the mouth (Chvostek’s sign). Questions:

There are no palpable masses in the thyroid bed. A
blood pressure cuff inflated above the systolic pressure 1. What is the patient’s acid–base status?
induces involuntary muscle contracture in the ipsilateral Metabolic Acidosis
hand after 60 seconds (Trousseau’s sign). Labs are
notable for calcium 5.6 mg/dL (normal, 8.5 to 10.2 2. Why is the HCO3 − level so low?
mg/dL), albumin 4.1 g/dL, BUN 20 mg/dL, and creatinine
1.0 mg/dL. PTH is undetectable at <1 pg/mL. Diarrhea loss of HCO3
3. Why does the patient have rapid respiration?
Questions Partially compensating respiratory
Answers to Case Study 17-1
1. Which laboratory results are abnormal?
2. What condition is he experiencing since his
thyroidectomy? 1. metabolic acidosis 2. Persistent diarrhea
3. What is the cause of this symptomatic condition? causes significant loss of HCO3–. 3. The
4. What is the treatment for this patient, in addition to patient’s rapid respirations reflect a
thyroxine medication? compensatory mechanism to decrease the
PCO2 level and restore the 20:1 ratio
(HCO3 /PCO2) and the pH to 7.4.

Case Study 17-2

An 80-year-old woman fell on the ice and fractured her

femur. After several hours, when she arrived at the
emergency department, she was anxious, panting, and
complaining of severe chest pain and not being able to
breathe. Her pulse was rapid (tachycardia) as was her
respiration rate (tachypnea). Blood gases were drawn
and yielded the following results:
pH = 7.31
pCO2 = 22 mm Hg
HCO3 = 12 mmol/L
sO2 78% (calculated) (reference range, >95%)
 MLT 132 Clinical Chem I

Week 4 CAL MAG PHOS/ pH/Acid /Base HW Assignment

3. Once the respiratory component returns to normal,

Questions: what will be the patient’s expected acid–base status?
1. What is the patient’s acid–base status?

2. Why is the HCO3 − level so low?

Answers to Case Study 17-3

3. What caused the acid–base imbalance? 1. The patient’s blood gas data indicate
respiratory and metabolic acidosis.
Answers to Case Study 17-2 Respiratory acidosis is indicated by elevated
PCO2; metabolic acidosis is indicated by
1. Partially compensated metabolic acidosis decreased HCO3–. 2. Secobarbital depresses
2. The HCO3– level is the primary contributor the breathing center; consequently, CO2 is
to nonrespiratory acidosis. The PCO2 level is not eliminated effectively and sufficient O2 is
low as a result of the patient hyperventilating not taken into the lungs. 3. metabolic
and blowing O2 in an attempt to restore the acidosis. Appropriate ventilation will correct
20:1 ratio and return the pH to 7.4. 3. the respiratory component, returning PCO2
Pulmonary fat emboli are a major, serious and PO2 to normal. The decreased HCO3–
complication of long-bone fractures in the level will take longer to return to normal.
elderly. Tachycardia, tachypnea, and low
PO2 values, together with chest pain, are the
classic signs. Globules of fatty marrow from
the fracture enter small veins in the area of
the fracture and travel to the lung,
obstructing pulmonary circulation.

Case Study 17-3

A 24-year-old graduate student was brought to the

emergency department in a comatose state after being
found unconscious in his room. A bottle of secobarbital
was there on his bed stand. He did not respond to
painful stimuli, his respiration was barely perceptible,
and his pulse was weak. Blood gases were drawn and
yielded the following results:
pH =7.10

pCO2 =70 mm Hg

pO2 =58 mm Hg

HCO3 = 20 mmol/L

O2Hb 80% (reference range, >95

Questions:

1. What is the patient’s acid–base status?

Respir / Metabolic Acidosis

2. What caused the profound hypoventilation?

 MLT 132 Clinical Chem I

Week 4 CAL MAG PHOS/ pH/Acid /Base HW Assignment

Case Study 4 urine. Lasix is used to treat fluid retention

(edema) in people with congestive heart failure,
A 64-year-old woman with COPD was admitted to the liver disease, or a kidney disorder such as
emergency department with extreme shortness of nephrotic syndrome.
breath. She had a bluish color that was particularly
pronounced on her lips and nail beds and she displayed 2. Which critical electrolyte should be closely
a weak and persistent cough with diminished, but rattling monitored in the management of this case?
breath sounds. Home medications included
bronchodilators, steroids, Lasix (a loop diuretic that does Potassium in a very important electrolyte because it
not conserve plasma potassium), and digitalis. Vital monitors the heart function. Hypokalemia is known
signs: heart rate, 148 bpm; blood pressure, 100/88 mm to occur with water pills.
Hg; temperature, 37°C; and respiratory rate, 38/min.
Initial blood gas results on room air were the following:
pH =7.289

pCO2 = 91 mm Hg

pO2 =53 mm Hg

HCO3 = 43 mmol/L

Part 1 Questions:

1. What is the patient’s acid–base status?

Respiratory acidosis

2. Is her body compensating or uncompensated?

Why? Partially compensating bc HCO3 is high,
which is a base and it is trying to fix acidosis.

She was treated with a bolus of Lasix intravenously and

two albuterol (bronchodilator) respiratory treatments. Her
vital signs improved: heart rate, 124 bpm; blood
pressure, 120/80 mm Hg; and respiratory rate, 22/min.
Blood gases were repeated with the patient breathing
28% O2 (FiO2 = 0.28)

pH 7.306

PCO2 = 75 mm Hg

pO2 =78 mm Hg

HCO3 =36 mmol/L

Part 2 Questions:

1. How did Lasix administration and respiratory

treatment benefit the patient?
Yes values are getting lower and pH is getting
closer to its normal range. Lasix (furosemide)
is a loop diuretic (water pill) that prevents
your body from absorbing too much salt. This
allows the salt to instead be passed in your